FARAI CHIDEYA, host:
Two thirds of the HIV infections around the world occur in sub-Saharan Africa. Some experts say now is the time to change prevention priorities on the continent. The most common ways of trying to prevent the disease these days are condoms, HIV testing, STD awareness, and abstinence.
But a new Harvard study says they're not working. The paper's authors advocate male circumcision and reducing multiple sex partners.
Daniel Halperin is one of the paper's lead authors. He's also a senior research scientist at the Harvard School of Public Health. Welcome, Daniel.
Dr. DANIEL HALPERIN (Senior Research Scientist, Harvard School of Public Health): Hi. Glad to be on the show.
CHIDEYA: So, generally, how is HIV most commonly transmitted in Africa?
Dr. HALPERIN: Well, unlike most of the world, where HIV is mainly transmitted in what we call high-risk populations, which are sex workers and their clients, injection drug users and men who have sex with men, in many parts of Africa, HIV is mainly spread in the general population. It's spread mainly heterosexually, and a lot of the HIV transmission appears to be happening in regular, more regular partnerships, not so much casual sex or commercial sex.
But, often, you have a scenario where somebody might be married, but also has a boyfriend or girlfriend on the side. They don't necessarily perceive themselves as being at high risk of HIV infection, but, actually, they are high risk. Because if their partners have other partners who have other partners who have other partners and so on, then you - what you have is basically a large sexual network, where HIV can enter this network and spread around pretty quickly through the network.
CHIDEYA: I'm going to talk a little bit later about something that you've identified in Uganda that seems to work on that score. But first of all, why don't you tell us a little bit more about how you did the research, what you were looking for and what you found.
Dr. HALPERIN: We believe that all these approaches are important. We're not in any way advocating for the termination of programs that promote condoms, or for HIV testing, or for treating of other sexually-transmitted infections, or for abstinence. We feel all those approaches have some value.
But in terms of really trying to reduce the epidemic, in terms of really trying to bring down the rate of new infections, these approaches appear to have had relatively little impact versus - we've seen now several examples of countries where there's been a focus on reducing the number of sexual partners that one has. This was called zero-grazing in Uganda.
And we see now, not only in Uganda, but in several countries in Africa where HIV has gone down, the main behavioral change that's occurred has been a reduction in the numbers of partners. So, we feel that this is an approach that hasn't been employed very much, but could be much more focused on then than it has been.
CHIDEYA: In addition to the issue of sexual partners, you also talk about male circumcision. And before we get into that, there was a reporter in South Africa who actually had himself circumcised as an adult and explained the procedure.
He felt, clearly, very strongly, that this was something that would help. You seem to feel that way as well. Why?
Dr. HALPERIN: Well, there have been dozens, many dozens of studies now over the last 20 years, and more that strongly suggest that men who are not circumcised are at higher risk of HIV infection from heterosexual intercourse.
Consistently, we see at least a 60 percent reduction in risk for men who are circumcised. And it's a relatively simple surgical procedure. It takes about 15 or 20 minutes normally for adults. It's done under local anesthesia.
There's a lot of demand for it. In many African countries now, there are long wait lists at the public hospitals of men wanting to get circumcised, and there just are not the resources there for them to do it.
CHIDEYA: Thabo Mbeki, the president of South Africa, was reviled by some people when he said poverty was the cause of AIDS. Regardless of whether or not you think his statement is literally true, is there a grain of truth to it?
Dr. HALPERIN: Well, we actually tend not to agree. We think issues like poverty as well as rape and war and gender inequality, these kind of issues, which are often associated with AIDS in Africa, we believe there are probably some associations. We are certainly not in any way saying that poverty has no relationship with AIDS, or that gender inequality has no relationship.
But when we looked, again, very carefully at the evidence, if anything, the evidence seems to go in the other direction. In other words, in almost all African countries, HIV prevalence is higher, and in most cases much higher, in wealthier men and in wealthier women than it is the poorest people. In fact, 20 years ago, in the hard-hit - then hard-hit part of Africa, which is the Great Lakes Region around Uganda and Tanzania, the local people referred to AIDS as the fat man's disease, or the rich man's disease. They certainly saw it as something that wealthy people were suffering from.
And that's simply because wealthier men, in particular, can have more sexual partners than the poor men can. For the most part, not completely, but for the most part, the hardest-hit countries in Africa are the relatively wealthiest countries.
I mean, Thabo Mbeki is the president of South Africa, and there is certainly poverty in South Africa, but anyone who's been to South Africa knows that, relatively speaking, it's the richest, or one of the richest, most developed country in Africa.
And the parts of Africa that are really dirt poor, that are just - I mean, conjure up images of people just starving and facing tremendous poverty, that's really for the most part in West and Central Africa and some other areas, that tend to have actually relatively very low HIV levels.
So, while it's true that Africa is economically the poorest continent, and it's also the continent that has the most AIDS, within Africa the pattern actually goes in the opposite direction of what Mbeki was talking about.
CHIDEYA: You've been getting a lot of attention from the popular media, not just the science media, for this study. Where do you think this is going to take the conversation over AIDS in Africa?
Dr. HALPERIN: I don't know. That's a good question. I mean, in a sense, our - I suppose one of our objectives was to start a debate and start a discussion. We're not saying we have all the answers, but we do feel that we need to reassess HIV prevention, which was the title of the article. And so I'm glad that there has been apparently a fair amount of discussion about this.
I think one thing that's interesting to point out is that the approaches which we feel the evidence suggests could have the strongest impact in Africa, like promoting reduction in number of partners and male circumcision, are actually, in a sense, very much indigenous African approaches.
So, for example, the Zero Grazing campaign, that was started in Uganda over 20 years ago, was not developed by any foreigner or, you know, any international expert like myself. It was totally developed by the Ugandans themselves.
So, I think we really need to build more on the local culture, the local traditional leaders and traditional healers, you know, religious people and so on. And I think, in my experience working for a long time in Africa now, these kinds of approaches will tend to resonate.
I think people in Africa, and perhaps worldwide, tend to be somewhat suspicious of approaches that feel like they're being imposed on them from the outside. And I think, unfortunately, that has been part of the problem with condom programs.
But I think the idea that this a sexually-transmitted disease, that you're more at risk if you have more partners, seems logical to most Africans, and they can certainly grapple with that and understand that very clearly. And I think circumcision also is not something that's coming from the West.
So, perhaps Westerners need to have a little more humility about imposing what we think will work on Africa, but letting the Africans themselves develop effective approaches.
CHIDEYA: Well, Daniel, thanks so much.
Dr. HALPERIN: Sure thing.
CHIDEYA: Daniel Halperin is a senior research scientist at the Harvard School of Public Health's Department of Population and International Health. He's one of the lead authors of a paper which advocates new HIV prevention priorities in Africa. It appears in this month's issue of the journal, Science.
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